Diagnosis and Treatment

Treatment Options

Surgery

Transurethral surgery may be appropriate for early-stage or superficial bladder cancers. This is the least invasive type of surgery and involves the removal of the tumor without cutting into the abdomen. Unfortunately, patients with transurethral surgery often experience a reoccurrence of the cancer after the original tumor has been removed.
A second type of surgery called a cystectomy involves the complete or partial removal of the bladder. This type of surgery is used mainly for cancers that have invaded the muscle tissue. Often, the removal of the prostate in men, or the removal of the uterus, ovaries, fallopian tubes and a small portion of the vagina in women is also required.

Intravesical Therapy

Two types of intravesical therapies may be used for treatment of bladder cancer:

• Intravesical Immunotherapy: This type of therapy uses microorganisms or interferon to stimulate the immune system. A promising type of intavesical therapy is BCG therapy in which bacillus Calmette-Guérin bacterium is administered into the bladder (Medscape).
• Intravesical Chemotherapy: This treatment involves the insertion of chemotherapy drugs into the bladder to kill actively growing cancer cells.

Chemotherapy

Chemotherapy can be local or systemic. Local chemotherapy involves the deposition of drugs directly into the affected region. Systemic chemotherapy occurs when the drug is ingested to be absorbed into the bloodstream, or injected directly into the circulatory system.
Cisplatin-based neoadjuvent chemotherapy has been shown to increase survival rate of patients with muscle invasive bladder cancer. Chemotherapy increasingly starts as soon as the cancer is diagnosed, so researchers need to have realistic expectations about the likelihood of obtaining pre-treatment bladder cancer samples.

Radiation Therapy

Radiation therapy involves the use of high-energy radiation to shrink or kill cancer cells. Often, radiation therapy is used in combination with other types of therapies.

Please see http://www.cancer.org/cancer/bladdercancer/detailedguide/bladder-cancer-treating-general-info for more extensive information on any of the above treatment options.

Standard of Care

Diagnosis

Cystoscopy is considered the best resource in the diagnosis of bladder cancer. Bladder cancer is rarely diagnosed postmortem due to the clinical presentation of the disease. MRI and CT scans have low sensitivity to the cancer and additional testing may be required if bladder cancer is suspected. Surveillance of early stage bladder cancer after treatment is required. Approximately 50% of patients initially diagnosed with high-grade bladder cancer already have invasive disease. After a cystectomy, examination of 9 lymph nodes is sufficient for assessment of the bladder cancer stage.

Treatment

Non-invasive tumors (Ta) and tumors in-situ (T1) are treated by the direct removal of the cancerous tissue from the bladder (transurethral resection), with recurrence rate as high as 50-70%. If the cancer reappears, the physician may perform another transurethral resection. This process may occur several times before more extreme treatment measures are considered. Because non-invasive tumors and tumors in-situ are so commonly resected, bladder cancer samples of this type will often be available. 10-20% of patients who undergo transurethral resection procedures alone will eventually have the cancer progress to an invasive stage. Transurethral resection in combination with intravesical BCG therapy results in a better outcome than transurethral resection alone. Approximately 20% of non-invasive tumors can be removed through surgery without recurrence of the cancer (far less than the recurrence rate with transurethral resection alone) and only about 10-30% of these eventually progress to invasive disease. Flat carcinomas are diagnosed at the superficial stage approximately 70% of the time and progress to invasive disease in about 5-10% of these cases. Therefore, samples of flat carcinoma bladder cancer that has progressed to the invasive form of the disease may be harder to come by. Most deaths due to bladder cancer are attributed to invasive stages of the disease.
The standard treatment for invasive bladder cancer is a cystectomy with removal of all tissue within the genitofemoral nerve laterally, the bladder medially, the circumflex iliac vein inferiorly (known as the lymph node of Cloquet), the bifurcation of the common iliac artery superiorly, and the hypogastric blood vessels posteriorly. Because much of the tissue removed is normal, samples of both normal and diseased tissue from the same patient will commonly be available. Several different types of tissue, including lymphatic tissue, within the resected area may also be available from the same patient. The general prognosis of patients undergoing this treatment is poor with the majority of these patients dying of metastases within 3 years.

Relevant Findings

Mutations in HRAS and FGFR3 are linked to low grade non-invasive papillary tumors. Invasive Bladder cancers have been linked to mutations or deletions in tumor suppressor genes, including TP53, Rb and PTEN. Telomerase activity is detected in all superficial urothelial cancer cells.

Please see http://standardofcare.com/Bladder_cancer for more information on standard of care.

 

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